S.C.A.

T
SESSI 7

ACCIDENT/
INCIDENT
INVESTIGATION

Accident/Incident
Investigation

SCAT
Systematic
Cause
Analysis
Technique

Objectives

Attendees will understand the process of

accident and / or incident causation.

Attendees will have a thorough understanding
of the SCAT chart and its methodology of
determining causes.

Attendees will understand a simple and
practical technique valuable in determining if
an investigation of an accident or incident has
been thorough enough.

Overview

Introduce a systematic approach to

investigation

Review Loss Causation Model

Orient SCAT chart

Identify causes and control activities

Determine necessary control actions

SCAT Benefits

Excellent for checking investigation

effectiveness

A system for analyzing and evaluating causes

A system for developing control effectiveness

Reinforces the Principle of Multiple Causes

A reminder of causes and control of accidental
losses

Reasons for Inadequate Causal

Identification
1.
2.
3.
4.
5.

Failure to do a good investigation

Failure to take enough time
Failure to use a systematic approach
Forgetting previous training
Improper motivation

Reasons for Inadequate Causal

Identification
6.
7.
8.
9.
10.

Lack of method for checking results

Identifying only obvious causes
Many causes easy to overlook
Some causes difficult to identify
Causes selected haphazardly

Principle of Multiple Causes

Accidents and other

problems are seldom,
if ever, the result of a
single cause.

Loss Causation Model

LACK OF
CONTROL

BASIC
CAUSES

IMMEDIATE
CAUSES

INCIDENT

LOSS

Event

Unintended
Harm
and / or
Damage

Inadequate:
System
System
Standards
Compliance
to System
Standards

Personal
&
Job/
System
Factors

Substandard
Practices,
Acts
&
Conditions

Threshold Limit

Loss Causation Model

LOSS

Unintended
Harm
and / or
Damage

People
Property
Process
Product
Planet
Profit

Loss Causation Model

INCIDENT

EVENT

Events are Normally

Contacts with an Energy
Source or Substance:
Struck Against
Struck By
Caught Between
Contact With

Caught In
Fall To
Fall On
Overstress

Loss Causation Model

Examples:
IMMEDIATE
CAUSES
SUBSTANDARD
ACTS,
PRACTICES,
&
CONDITIONS

Substandard Acts Substandard

& Practices
Conditions
Failure to warn
Failure to secure
Improper lifting
Failure to use PPE
Horseplay
Defective Tools
etc.

Inadequate guards
Inadequate PPE
Congestion
Excessive Exposures
Disorder
Noise
etc.

Loss Causation Model

BASIC
CAUSES
PERSONAL
&
JOB/
SYSTEM
FACTORS

Job /System
Factors

Personal Factors

Inadequate:
Inadequate:
- Leadership
- Capability
- Engineering
- Knowledge
- Purchasing
- Skill
- Tools / Eqpt.
Stress
- Work Standards Improper Motivation
Wear and Tear
Abuse and Misuse

Loss Causation Model

LACK OF
CONTROL
INADEQUATE:

Is there a loss control management

in place?
Are there system standards?

SYSTEM
SYSTEM
STANDARDS
COMPLIANCE
TO SYSTEM
STANDARDS

Are the standards adequate?

Is there compliance to system
standards?
At what level is the compliance?

Loss Causation Model

The Management Work for Loss Control Success:
1. Leadership & Administration
2. Leadership Training
3. Planned Inspections & Maintenance
4. Critical Task Analysis & Procedures
5. Accident / Incident Investigation
6. Task Observation
7. Emergency Preparedness
8. Rules & Work Permits
9. Accident / Incident Analysis
10. Knowledge & Skill Training

11. Personal Protective Equipment

12. Health & Hygiene Control
13. System Evaluation
14. Engineering &Change Management
15. Personal Communications
16. Group Communications
17. General Promotion
18. Hiring & Placement
19. Materials & Services Management
20. Off-the-Job Safety

Systematic Cause Analysis Technique

Description of accident / incident
Evaluation of loss potential
Type of contact or near contact
Immediate / direct causes
Basic / underlying causes
Control action needs

Gaining Compliance with

Standards

Communicate standards

Review and update standards

Reinforce performance to standards

Reeducate / review for understanding

Practice progressive discipline

Sources of Loss / Control

Opportunities for

P
E
M
E

People
Equipment
Materials
Environment

Status of Current Control Activities

P: Do we have a system and / or system standards for this activity?
Yes
or
No
If No, check P and begin by developing a system and / or system
standards.
S: Are existing system standards adequate?
Yes
or
No
If No, check S and develop adequate system standards.
C: Is there full compliance with system standards?
Yes
or
No
If No, check C and develop means to ensure compliance.

Factors Determining
Control Actions
1. Risk of further losses?
2. Potential for other types of losses?
3. Investigation quality?
4. Extent of management participation?
5. Funds, time, manpower available?
6. Level of control excellence desired?

Guide to Risk Decisions

1. Potential loss severity if an accident occurs:
A - Major
B - Serious
C - Minor
2. Probability that loss will occur:
A - High
B - Moderate

C - Low

3. Cost of recommended control:

A - High
B - Medium

C - Low

4. Degree of control:
A - Substantial
(67 - 100%)

C - Low
(0 - 33%)

B - Moderate
(34 - 66%)

5. What are the alternatives?

6. Justification: Why were the control(s) suggested?

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